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Full text of "United States Navy Medical News Letter Vol. 33 No. 4, 20 February 1959"

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NavMed 369 




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Rear Admiral Bartholomew W. Hogan MC USN - Surgeon General 
Captain Leslie B. Marshall MC USN (RET) - Editor 



Vol. 33 



Friday, 20 February 1959 



No. 4 



TABLE OF CONTENTS 



Gamma Globulins and Their Clinical Significance 2 

Photofluorography in Tuberculosis Control 8 

Post-Myocardial-Infarction Syndrome 11 

Idiopathic Hypercalcemia 13 

Pituitrin for Bleeding Esophageal Varice s 15 

Strangulated Femoral Hernia 17 

"To Comfort Always" 19 

From the Note Book 20 

Right to Drive 22 

Anesthetic Difficulties 23 

Board Certifications 23 

Recent Research Reports 24 

Hearing Conservation Program (BuMed Inst. 6260. 6A) 25 

Disposition of Allied Patients (BuMed Inst. 5711. 1) 26 

Physical Qualification Certification - FAA (BuMed Inst. 6120. 11B) 26 

DENTAL SECTION 

Endodontics Training Films 27 Letter of Commendation 27 

RESERVE SECTION 

Tissue Bank Training 28 Medical Military Training 28 

Pest Control Courses 29 

AVIATION MEDICINE SECTION 



Atomic Flash Blindness & Burns .30 
Bone Marrow Embolism ......... .32 

Anthropometric Data 33 

Squadron Flight Surgeons 36 

Letter of Commendation 37 

New JCAP Officers . . . 



1959 AeroMed Meeting 38 

Aviation Toxicology 39 

Walking Blood Bank 39 

CAA now FAA 39 

Flight Time 40 

. 40 



Medical News Letter, Vol. 33, No. 4 



Policy 



The U. S. Navy Medical News Letter is basically an official Medical 
Department publication inviting the attention of officers of the Medical 
Department of the Regular Navy and Naval Reserve to timely up-to-date 
items of official and professional interest relative to medicine, dentistry, 
and allied sciences. The amount of information used is only that necessary 
to inform adequately officers of the Medical Department of the existence 
and source of such information. The items used are neither intended to be, 
nor are they, susceptible to use by any officer as a substitute for any item 
or article in its original form. All readers of the News Letter are urged 
to obtain the original of those items of particular interest to the individual. 

****** 
Gamma Globulins and Their Clinical Significance 

The separation of gamma globulins from human plasma for use in the 
prevention and treatment of infectious diseases was made possible during 
World War II by the procurement of large plasma pools by the American 
Red Cross and by the successful development of human plasma-fraction- 
ation techniques. Although the gamma-globulin fraction (fraction II of Cohn) 
contains almost all the plasma antibodies against many bacteria and viruses, 
"the specific antibody content of any given lot of gamma globulin depends 
entirely upon the particular immune antibodies present in the plasma of the 
donors. The concentration and variety of specific antibodies depends upon 
previous immunizations, previous clinical and inapparent infections with 
endemic and epidemic infectious agents, and the time of such events in 
relation to the time of the blood donation. Everyone's past immunologic 
experience -is somewhat different, but variations in antibody content against 
.comm'on infectious agents like the measles virus in different lots of gamma 
globulins are minimized by pooling of the plasma of a large number of per- 
sons before fractionation. 

In addition to the differences in antibody content among individuals in 
the same community, there may be wide variations between whole populations 
in different geographic areas. For example, lots of gamma globulin obtained 
from persons in the eastern United States contain higher titers of diphtheria 
antitoxin than lots derived from plasma obtained in the Far West, On the 
•other hand, western — but not eastern — gamma globulin contains antibodies 
to the virus of western equine encephalitis. However, for the ubiquitous 
diseases in which gamma globulin is most commonly used, such as measles 
and infectious hepatitis, antibody titers appear to be fairly uniform in lots 
derived from different parts of the country and even from other countries. 






Medical News Letter, Vol. 33, No. 4 



Pooled concentrated gamma globulin is derived from plasma pools 
of normal healthy donors. It contains antibodies in a titer adequate in most 
cases for the prevention or attenuation of such viral infections as measles, 
German measles, infectious hepatitis, and poliomyelitis, and for the pro- 
phylactic treatment of recurrent invasive bacterial infections in agamma 
globulinemia. However, such gam ma -globulin preparations often contain 
antibody titers too low to be consistently effective against certain other 
infections. Hyperimmune or convalescent-phase gamma globulin may than 
be effective. This is derived from the pooled plasma of individuals 4 to 8 
weeks after specific immunization or at a comparable time during conval- 
escence from a particular infection. It has been especially useful in the 
control of generalized vaccinia and its complications, in the prevention of 
mumps orchitis and pertussis, and should prove to be more consistently 
potent than ordinary gamma globulin in the prevention of German measles. 

Concentrated gamma globulin is given intramuscularly or subcutan- 
eously only — never intravenously. Intravenous administration may cause 
severe cardiac arrhythmia, hypotension, and hyperpyrexia in sick children. 
Intramuscular injections provide*a peak serum level by the second day after 
injection so that intravenous administration under ordinary circumstances 
offers no particular advantage with respect to time. 

Toxic reactions are not uncommon. A figure of 1. 2% has been report- 
ed after small intramuscular doses for measles prevention. A local inflam- 
matory reaction causing pain and tenderness at the site of injection, mild 
systemic reactions of malaise, headache, and low-grade fever may occur. 
More severe reactions are rare, but a few isolated cases of angioneurotic 
edema, nephrotic syndrome, neuromyelitis optica, and even anaphylactic 
shock have been reported after routine administration of gamma globulin 
to a large number of persons throughout the country. 

Gamma globulin has proved effective in the prevention of severe re- 
current bacterial infections in all three forms of agammaglobulinemia: 
transient agammaglobulinemia of infancy as well as the congenital and 
acquired forms of the disease. Antibiotics have been more effective than 
gamma globulin in terminating any specific infection, but not in long-term 
prophylaxis. In some cases, both antibiotics and gamma globulin have been 
required. 

Measles. The measles virus will cause clinical infection in 80 to 85% 
of nonimmune persons after intimate exposure at home. Gamma globulin 
is effective in both preventing and attenuating measles. Complete preven- 
tion can be attained in 80% of intimately exposed, susceptible children by 
a dose of 0. 1 ml. per pound of body weight given during the first 6 days 
after exposure. Attenuation can usually be attained by a dose of 0. 0Z ml. 
per pound given during the first 6 days after exposure. The authors are 
of the opinion that all healthy nonimmune exposed children should receive 



Medical News Letter, Vol. 3 3, No. 4 



attenuating doses of gamma globulin. Attenuation markedly reduces the 
number of complications frequently seen in unmodified cases. There is 
suggestive evidence that attenuation also lowers the prevalence of enceph- 
alitis and diminishes the severity of an attack when it occurs in the face 
of gam ma -globulin prophylaxis. 

Complete prevention may be indicated in the following clinical settings: 
in children up to 3 years of age when mortality rates are highest; in a patient 
suffering with a .concurrent illness; in debilitated persons; in nonimmune 
pregnant women who have been exposed, in whom measles infection may in- 
duce premature labor and even abortion; in persons who must travel or con- 
tinue work during the anticipated period of symptomatic illness; and in those 
who are in an environment where they may infect a large group, for example, 
in a hospital ward, institution, or military establishment. If measles occurs 
in a patient on a hospital ward, one may keep the ward open by injecting all 
susceptible exposed patients and all patients admitted during the next 3 weeks 
with 0. 1 ml. per pound of body weight. Such passive protection lasts about 
3 weeks. Therefore, if a secondary case occurs, gamma globulin in the 
same dosage should be repeated no later than 3 weeks after the first dose 
was given. 

German measles. Recent controlled studies have corroborated sug- 
gestive observations that immune gamma globulin is effective therapy in 
the prevention of German measles if given before exposure or early in the 
incubation period. 

A previous study of an institutional outbreak of rubella found that pro- 
tection after exposure could be attained with a dose of 0. 1 ml. per pound 
of body weight beginning 3 days after injection and lasting for 15 days. In 
several persons, rubella developed within 3 days after injection of gamma 
globulin, suggesting that it is not protective in this dosage if given late in 
the incubation period. Because the incubation period.is 10 to 21 days, 
gamma globulin should be administered within a week after exposure. 

The only direct indication for the prevention of German measles is in 
pregnant women exposed to the rubella virus during the first 4 months of 
•pregnancy. Prospective studies show that the postrubella syndrome occurs 
in 10 to 12% of newborn infants whose mothers contracted rubella during 
the first trimester of pregnancy — a rate of congenital malformations that 
is 6 to 8 times that in controls. The postrubella syndrome is characterized 
by congenital cardiac defects (especially patent ductus arteriosus), blindness 
(congenital cataracts), deafness, and sometimes microcephaly with mental 
deficiency. Gellis has used a dose of 20 to 30 ml. of gamma globulin pooled 
from three different lots to minimize variations in antibody content. No clin- 
ical rubella has occurred in his series of 45 pregnant women initially ex- 
posed to the disease who were given this dosage. 

Infectious he patitis (viral hepatitis A). Of all the viral infections 
in which gammaglobulin preventive therapy has been studied, the most 



Medical News Letter, Vol. 33, No. 4 



consistently effective results have been observed in measles and infectious 
hepatitis. Both of these diseases produce lifelong immunity after clinical 
or subclinical infection. More than 95% of all adults are estimated to have 
immunity to measles; at least 40% have immunity as judged by skin tests 
to infectious hepatitis, but the infrequency of this disease in adults over 30 
suggests that inapparent infection and immunity are much more frequent 
than this figure. 

Protection against infectious hepatitis can be achieved with a dose as 
low as 0. 01 ml. per pound of body weight given within 7 days before the onset 
of symptoms. Because the incubation period is 21 to 42 days, it should prob- 
ably be given within 14 days after exposure. 

Prevention is indicated in the following clinical settings: in children 
under one year of age in whom the disease is often serious; in children with 
a concurrent illness; in adults in whom the disease may be severe and espec- 
ially in postmenopausal, pregnant, or amenorrheic women who are particu- 
larly prone to a stormy course; and in persons going into endemic areas 
(underdeveloped countries, particularly tropical, where sanitation is poor). 

At this time, there is little evidence that gamma globulin is effective 
in the prophylaxis, of serum hepatitis or homologous -serum jaundice. 

Poliomyelitis. Gamma-globulin prophylaxis apparently has a modi- 
fying effect on the paralytic complications of clinical poliomyelitic infections 
if given during the first 5 to 7 days of the incubation period of 10 to 12 days. 

Among an unvaccinated population, gamma globulin is probably most 
effectively used when given to the families of victims of paralytic poliomye- 
litis. In about 41% of household contacts, a subclinical infection will develop 
as manifested by the appearance of virus in feces. Three to five percent of 
all families with a primary paralytic case will be stricken with a second 
paralytic case— a prevalence ten times that among the other families of the 
community. Of the secondary cases among such household contacts, 60% 
will occur within 5 days after diagnosis of the primary case. If gamma 
globulin were given to these contacts at the time of diagnosis, this group 
would not appear to be protected. However, another 30% of secondary cases 
will occur from 6 to 12 days after diagnosis of the primary case, and this 
group could be expected to have a paralytic attack of lesser severity if 
gamma globulin were given at the time of the diagnosis of the primary case. 
The remaining 10% of patients with secondary cases occurring 13 to 30 days 
after the primary case among household contacts would be protected by 
gamma globulin. The two groups occurring after the fifth day (40% of the 
total household contacts) who should benefit from gamma globulin include 
a higher proportion of older children and adults who ordinarily have a 
higher prevalence of bulbar complications and of severe paralysis and a 
higher mortality rate. 

At the end of 1957, 40,000,000 persons in the United States under 
the age of 40 were still unvaccinated against poliomyelitis. Moreover, 



Medical News Letter, Vol. 33, No. 4 



an inadequate course of vaccine does not necessarily confer protection. If 
an outbreak of poliomyelitis occurred in a confined population, limitations 
in the supply of gamma globulin and the logistic problems involved in its 
rapid injection into a large number of people might force a system of prior- 
ities. Such a system must always try to reconcile a number of epidemio- 
logic facts: young children have the highest attack rate of infection; adults 
have a much lower attack rate, but those attacked have a much higher rate 
of severe paralysis and mortality; pregnant women are particularly vulner- 
able; the attack rate among household contacts of paralytic cases is ten 
times as high as that in the general community; bulbar poliomyelitis occurs 
more frequently among those who have had a previous tonsillectomy. There 
seems little doubt that gamma globulin is most effective in protection 
against poliomyelitis when given before exposure. Much of the argument 
over its use arises from the inherent practical difficulties — so different 
from the situation in measles — of recognizing when exposure has taken place 
and hence of administering gamma globulin immediately after exposure. 

Variola and vaccinia . Kempe et al. recently introduced the use of hyper- 
immune gamma globulin in the prophylaxis of smallpox and in the therapy of 
serious dermal complications of vaccination; eczema vaccinatum, progressive 
vaccinia, and generalized vaccinia. 

The combination of hyperimmune gamma globulin and vaccination appears 
to be the therapy of choice in the prophylactic treatment of a susceptible person 
exposed to smallpox. Gamma globulin given 12 to 24 hours after vaccination 
does not impair the development of the active immune response. In fact, 
there was a lower prevalence of smallpox and a lower mortality in one small 
series after the combined gamma globulin and vaccination therapy than after 
vaccination alone. 

Eczema vaccinatum is a serious disease with a 30 to 40% mortality 
during the first 2 years of life. Hyperimmune gamma globulin has been used 
with encouraging results, both prophylactic ally for children with eczema ex- 
posed to a vaccinated sibling or entering an endemic area, and therapeutically 
for the treatment of established cases at dosages of 0. 6 to 1.0 ml. per kilo- 
gram of body weight and repeated if necessary. 

Progressive vaccinia is one of the most serious complications of vac- 
cination. The primary vaccination site fails to follow a normal course of 
vesiculation with subsequent umbilication and healing, but continues to en- 
large by direct extension and satellite vesicles. A viremia occurs with dis- 
semination of new lesions of the skin, mucous membranes, and internal organs. 

Generalized vaccinia is characterized by the appearance of vesiculo- 
pustular skin lesions 6 to 10 days after vaccination as the result of a viremia. 
It is usually benign with a self -limited course, but hyperimmune gamma glo- 
bulin in a dose of 0. 6 to 1. ml. per kilogram of body weight may halt the 
further appearance of new satellite lesions within 24 to 48 hours after admin- 
istration. 



Medical News Letter, Vol. 33, No. 4 7 

Mumps. Ordinary gamma globulin had no effect either in preventing 
mumps or in lowering the incidence of orchitis in military personnel, even 
when given in 50-ml. doses with 24 hours after the onset of parotitis. But 
gamma globulin prepared from mumps convalescent serum, given in a dose 
of 20 ml. lowered the incidence of orchitis from 27 to 8% when administered 
within 24 hours after the onset of parotitis. 

Other viral diseases. The use of gamma globulin in many other dis- 
eases has been tried and the results recorded as case reports or small 
series that are suggestive but not statistically significant. 

Aside from its usefulness in the general prevention of bacterial infec- 
tion in patients with agammaglobulinemia, gamma globulin has found appli- 
cation in the prophylaxis and therapy of a variety of specific bacterial infec- 
tions. The injection of 2. 5 ml. of hyperimmune antipertussis gamma 
globulin with a repeated dose 5 to 7 days later has been effective in preventing 
pertussis in about 75% of nonimmune children exposed to the disease. The 
gamma globulin should be given as early in the incubation period as possible. 
It may also be used in larger doses in the treatment of pertussis in infants. 
Gamma globulin has been used in experimental and clinical infections due to 
Staph, aureus, S. typhimurium, Pseudomonas aeruginosa and proteus. The 
exact mechanism of action of gamma globulin in these cases is not clear, but 
the present evidence suggests that protection is afforded by its specific anti- 
body content, not nonspecific factors. It has been reported that gamma glo- 
bulin and various antibiotics act synergistically and effectively against a 
number of bacteria; this combination has been used successfully in the treat- 
ment of cases of chronic osteomyelitis and chronic pyelonephritis after 
antibiotics alone had been ineffective. There has been an increasing tendency 
toward giving gamma globulin prophylactically to children who are afflicted 
with repeated attacks of otitis media and tonsillitis, but the results are inade- 
quate at this time for a sound clinical judgment. 

Because human tetanus and diphtheria antitoxins are gamma globulins, 
hyperimmune gamma globulin might be useful in the unusual cases in which 
the specific person is allergic to equine or bovine antiserum. Commercial 
production of such human antitoxins is just beginning. (Gross, P. A, M. , 
Gitlin, D. , Janeway, C. A. , The Gamma Globulins and Their Clinical 
Significance (Concluded) IV. Therapeutic Uses of Gamma Globulins: New 
England J. Med., 260 :170-177, January 22, 1959) 

sjc g; iff jjt $ $ 

Use of funds for printing this publication has been approved by the 
Director of the Bureau of the Budget, 19 June 1958. 

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Medical News Letter, Vol. 33, No. 4 



Photofluorography in Tuberculosis Control 

The primary goal of the Tuberculosis Control Program in the Navy 
is to prevent dissemination of this communicable disease through detection 
of personnel suffering from tuberculosis in its earliest stages. Thus, the 
exposure of healthy associates to the disease is minimized and treatment 
of these individuals can be accomplished at a time when the best results 
can be obtained. Periodic evaluation of the effectiveness of the program, 
which has been described elsewhere, is necessary to insure that this objec- 
tive is being obtained to a degree that makes continuation of the program 
economically and medically worthwhile. The present study was made to 
find how effective a contribution routine photofluorographic screening makes 
to the program. Primary interest lies in the periodic or annual photofluoro- 
gram. 

The pilot study reported which utilized a sampling technique was con- 
sidered to be one method of evaluating this program. The particular objec- 
tive was to determine the percentage of cases of established tuberculosis 
brought under treatment as a result of original detection by routine photo- 
fluorographic procedures, this being the principal case finding method 
applicable to the Navy and Marine Corps as a whole. The assumption is 
made that detection by photofluorographic screening resulted in early isola- 
tion and therapy of cases which might have progressed for some time before 
symptoms or some other illness would have resulted in discovery of their 
disease. Thus, a more prolonged exposure of infected personnel to their 
associates was prevented. The study had these specific objectives: 

1. To determine the proportion of total cases of tuberculosis occupy- 
ing beds at the two special treatment hospitals during the year 1955 
which had originally been detected by photofluorographic screening, 

2. To determine what proportion of the cases discovered by photo- 
fluorography were detected by routine periodic 70 mm. photofluorography 

3. To determine the actual time spread between periodic examinations 
in the cases reviewed. 

4. To determine the proportion of cases of tuberculosis revealed only 
in a second reading of the photofluorograms. 

Routine chest roentgenographs examinations are made of both military 
and civilian personnel upon their entering service, upon their separation 
from service, and at annual intervals when practicable. Survey x-ray inspec- 
tions are taken in almost all instances by 70 mm. photofluorographic techniques. 
An immediate interpretation of the film is made at the various stations and 
14 by 17-inch films are ordered for those individuals whose 70-mm. films 
reveal suspicious findings. If the suspicious area is verified by the 14 
by 17-inch film, the service man is sent to a naval hospital for consultation 
or admission as appropriate. Each month, all 70-mm. films that have been 
taken are mailed to the Tuberculosis Control Section of the Bureau of Medicine 



Medical News Letter, Vol. 33, No. 4 



and Surgery, Navy Department, Washington, D. C. , where they are again 
reviewed. The films are accompanied by a log that gives adequate identi- 
fication of each film by the interpreting physician. If a 70 -mm. film that 
was interpreted as negative in the field is found to be suspicious in the 
course of re-reading, a request for follow-up is sent to the activity where 
the individual is stationed. Personnel with chest disease suggested as being 
tuberculous are isolated, studied, and treated in United States Naval hospi- 
tals, with further transfer of such patients to established pulmonary diagnostic 
and treatment centers at St. Albans, N. Y. , and San Diego, Calif. 

A Table shows the total number of cases reviewed and the reasons for 
their admission to hospitals. They are classified as to whether the patients 
were admitted because of symptoms referable to chest conditions; or were 
discovered by use of 70-mm. photofluorograms; or because of unrelated 
conditions and later found to have tuberculosis. 

A second Table classifies the patients who were admitted because of 
routine 70-mm. photofluorographs into separate categories according to 
reasons for the photofluorograph. These are subdivided into entrance exam- 
inations, separation examinations, re -enlistment examinations, and routine 
periodic examinations. 

The routine annual periodic examination of all personnel on active duty 
was responsible for 61% of all cases discovered by 70-mm. photofluorography. 
Also, of the 301 cases reviewed, it was responsible for 34% of the total. It is 
of interest to note that 24 cases of active pulmonary tuberculosis were dis- 
covered in enlistment films, which is 8% of the total cases reviewed. Some 
of these individuals had previously been examined by a chest x-ray film before 
coming on active duty and their films interpreted as negative. Others failed 
to have a preinduction film taken due to lack of facilities or for other reasons. 

A third Table reveals the time interval in each of the three main groups 
since the last film was taken, with a further breakdown of subdivisions under 
70-mm. film. 

A fourth Table is a compilation of the results of second reading of films 
at the Bureau of Medicine and Surgery. The value of such a second reading 
has been proved many times, but has always been of interest in a strict 
analysis of how many actual cases of active pulmonary tuberculosis were 
being discovered by this review. 

Of the 168 cases discovered by the 70-mm. photofluorography, 18 
(11%) initially interpreted as negative or within normal limits were later 
proved to show active tuberculosis as a direct result of film review. 

The method described in this study was selected for several reasons. 
In the first place, the data desired for analysis is not always incorporated in 
medical records, but could be obtained in all cases in the present study by 
direct interrogation of the hospitalized patient. Secondly, because less than 
1% of individuals reported to have abnormal chest x-ray films are finally 
shown to have active pulmonary tuberculosis, such a sample analysis obviated 



10 Medical News Letter, Vol. 33, No. 4 



the unfruitful search of many records later found to be unsuitable for anal- 
ysis. Thirdly, because patients with chronic pulmonary disease are gen- 
erally under observation and treatment at Navy Tuberculosis Centers for 
an average of 3 or 4 months, the majority of pulmonary tuberculosis cases 
discovered in the Navy and Marine Corps through the year could thus be 
personally interviewed when quarterly roster reports were made out. The 
final tabulations showed this to be true as the cases reported represented 
approximately 90% of all new cases of active pulmonary tuberculosis dis- 
covered in the Navy during this period. 

Anderson has said that periodic x-ray film examinations of healthy 
people is necessary to keep the prevalence of tuberculosis at a low level 
until better methods are found. Britten and Charter in a previous study 
of Naval and Marine Corps personnel pointed out that a large number of 
cases of active tuberculosis were discovered in personnel after 'years of 
active service, attesting to the need for periodic chest x-ray film exam- 
inations of all personnel over a long period. Other reports of Navy surveys 
have also indicated the value of photofluoroscopic chest surveys in the U. S. 
Navy, but none previously have demonstrated how many established cases of 
tuberculosis are actually discovered initially by the routine periodic x-ray 
film. 

No significant downward trend in the annual number of cases of sus- 
pected tuberculosis has been, noted in this program. Tuberculosis in all 
forms was the fifth leading cause of invaliding from the U.S. Naval Service 
during 1955. It is well known that the mortality rate from tuberculosis has 
declined steadily since the first of the century. Although this drop has been 
almost precipitous since the advent of chemotherapy and re sectional surgery 
during the past 10 years, Waring and others have pointed out that, unfortu- 
nately, the rate of new cases reported has not shown as marked a fall. 

The discovery of 24 cases of active tuberculosis among recruits at 
induction appears to reemphasize the need for preinduction films and the 
necessity for careful interpretation of them. The importance of this in 
enabling the Navy and Marine Corps to exclude infected personnel from pos- 
sible contact with healthy individuals at training centers and to minimize the 
number of disability pensions is recognized. It would seem that this is an 
area of control as yet incompletely solved. 

A review of 301 newly discovered cases of active pulmonary tuberculosis 
among Navy and Marine Corps personnel during 1955 was made. This represen- 
ted approximately a 90% sample of all such cases discovered during this period. 
The reasons for hospitalization of these patients included 111 cases (37%) ad- 
mitted because of symptoms; and 22 cases (7%) discovered to have pulmonary 
disease after admission to the hospital for unrelated conditions. Of the 168 
cases admitted because of abnormal 70-mm. photofluorograms, 102 (61%) 
were discovered by routine periodic annual examinations as contrasted to 
66 (39%) detected at the time of enlistment, re -enlistment into, or separation 



Medical News Letter, Vol. 33, No. 4 11 



from the service. A review or second reading of all films which is accom- 
plished routinely accounted for 18 of these 168 cases. 

It is shown in the present study that the majority of new cases of 
tuberculosis initially diagnosed in the U. S. Navy are discovered by means 
of photofluorography and the majority of such cases are detected by the 
periodic (annual) chest x-ray film. (Chace, J. F. CAPT MC USN, 
Coffay, E. P. Jr. M. D. , Role of Photofluorography in Navy Tuberculosis 
Control: Dis. Chest, XXXV : 22-27, January 1959) 

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Po st -My oc ardial-.Inf arction Syndrom e 

A complication of acute myocardial infarction which mimics the post- 
commissurotomy syndrome and idiopathic pericarditis has been described. 
The clinical features are fever, chest pain, evidence of pericarditis, pleu- 
risy, pneumonitis, and a tendency to recurrences. 

The present article reports additional information obtained in the 
past 2 years and stresses the danger of anticoagulant therapy in the pres- 
ence of the post-myocardial-infarction syndrome. 

Forty -four patients with recent myocardial infarction whose clinical 
picture did not conform to the textbook pattern of myocardial infarction 
were studied. There were prolonged and recurrent fever and chest pain. 
Relapses occurred frequently and caused prolongation of the clinical course 
by several weeks or months. Such features are usually attributed to recur- 
rent myocardial or pulmonary infarction. However, in the patients studied, 
electrocardiographic signs of extension of myocardial infarction were absent 
and there were no features indicative of phlebothrombosis in the lower extre- 
mities or obvious signs of pulmonary infarction. Instead, evidence of gen- 
eralized pericarditis with effusion often associated with pleurisy and pneu- 
monitis was observed. This triad, which closely resembles the postcom- 
missurotomy syndrome and idiopathic pericarditis has been referred to as 
the post-myocardial-infarction syndrome. 

Recognition of the post-myocardial-infarction syndrome is usually 
not difficult if one is aware of its occurrence. It may be suspected when the 
febrile period following the coronary attack lasts longer than a week and is 
accompanied by pain of pleuropericardial type or when fever and chest pain 
recur. The diagnosis is confirmed when a pericardial friction rub is audible 
for 3 days or longer or when it appears late in the course of the illness. 
Serial x-ray studies show in such cases, more often than not, evidence of 
pericardial effusion either single or combined with pleurisy and pneumonitis. 
In a few instances of this series, persistent sinus tachycardia during what 
appeared to be smooth convalescence after myocardial infarction led to the 
discovery of complicating pericarditis. 



12 Medical News Letter, Vol. 33, No. 4 



The diagnosis is difficult when pneumonitis is the earliest and dominant 
feature of the post -myocardial -infarction syndrome — also, when the symptoms 
of the coronary attack are mild and unrecognized and the patient presents 
himself first with manifestations of pleuropericarditis. It is advisable, ther- 
fore, whenever pericarditis of unknown etiology is present to include the 
post-myocardial-infarction syndrome in the diagnostic considerations. 

The true nature of this complication has remained unrecognized until 
recently because its manifestations lend themselves readily to erroneous 
interpretation. When pericardial effusion is present, "enlargement of the 
heart" seems to be a satisfactory radiological interpretation in the presence 
of myocardial infarction. Serial x-ray studies can readily correct the error 
in diagnosis by demonstrating shrinking of the cardiac silhouette. Recurrent 
chest pain and fever are often mistaken for extension of myocardial infarc- 
tion. It should be remembered that when the electrocardiogram clearly 
indicates massive myocardial infarction, prolonged or recurrent chest pain 
is rarely caused by extension of the infarction but more commonly by peri- 
carditis. The differentiation is readily made by asking the crucial question 
of whether or not the pain is aggravated by breathing and change in posture. 
An affirmative answer indicates that pericarditis is present; moreover, the 
electrocardiogram fails to show new changes which might result from exten- 
sion of the myocardial lesion. 

When chest pain is of pleuropericardial type or. when pleural effusion 
is present, pulmonary infarction is an important differential diagnostic con- 
sideration. Evidence of fibrinous pericarditis or pericardial effusion, which 
is not usually a feature of pulmonary infarction, supports the diagnosis of 
post-myocardial-infarction syndrome. 

Recognition of the post-myocardial-infarction syndrome is important 
not only with regard to saving the patient and his relatives a good deal of 
mental anguish, but also with regard to therapy. Anticoagulant therapy, 
which is used when extension of myocardial infarction or pulmonary infarc- 
tion is diagnosed, is dangerous and contraindicated in the presence of gen- 
eralized pericarditis. 

Because the condition is self -limited, it may not require any treatment 
when discomfort is slight or absent. In every case, it is of paramount impor- 
tance to give the patients convincing reassurance that the complication does 
not represent another coronary attack and that it is perfectly benign. When 
pain is a disturbing factor, it should be influenced by salicylates and codeine; 
in some instances, administration of meperidine or morphine is required. 

Adrenal steroids or cortocotropic hormone act almost in a specific 
way, relieving pain and fever within 24 hours. It is advisalbe to use the 
steroids with discretion, reserving this therapy for patients whose pain 
cannot be relieved by other means or whose course of illness is unduly pro- 
longed necessitating quick and effective therapy in order to lift their shattered 
morale. (Dressier, W. , The Post-Myocardial-Infarction Syndrome, A. M. A. 
Arch. bat. Med. , 103: 28-41, January 1959) 



Medical News Letter, Vol. 33, No. 4 13 



Idiopathic Hypercalcemia 

During the past two or three decades, descriptions of several new 
syndromes have been added to pediatric literature. Whether these are in 
fact new or only newly recognized is a moot point. Evidence would seem 
to show that what has been called idiopathic hypercalcemia, if not a new 
disease, has become a much more common biochemical finding than it used 
to be. Until recently, it was a rare condition for which there was usually 
a satisfactory explanation such as hyperparathyroidism, either primary or 
secondary, sarcoidosis, hype rvitamino sis D, the milk and alkali syndrome, 
or osteoporosis occurring in disease atrophy. It has been stated that hyper- 
calcemia is also found in interstitial plasma cell pneumonia, but the author 
has not observed such cases; from a study of those reported, it would seem 
likely that in some if not in all hype rvitamino sis D could not be ruled out. 

In 1952, Laghtwood and Payne described a syndrome occurring in 
infants which resembled to some extent hyperchloremic acidosis as des- 
cribed by Lightwood in 1935 but in which there was hypercalcemia. This 
article deals briefly with observations from a study of 33 cases belonging 
to the latter group. 

The ages of the 38 patients at the onset of the hypercalcemic condition 
varied from 3 weeks to II months. None of the infants were breast fed at 
the time. The onset as a rule was fairly sudden, the story being that of 
the development of anorexia, vomiting, loss of weight and, of course, con- 
stipation in an infant who had been thriving. Thirst was an important symp- 
tom, occurring in 19 of the 38 cases, and polyuria was seen less often. 
Vomiting, constipation, and anorexia were more frequent symptoms than 
thirst, but because they are common to so many diseases, were of less 
diagnostic significance. Also, specific inquiries about thirst were probably 
not always made. Constipation — often a source of worry to the mother— was 
much more intractable than usual. Hard fecal masses were as a rule read- 
ily palpable in the left iliac fossa. The anorexia was characterized by a 
refusal of solids and semisolids more than of fluids, but nevertheless 
resulted in considerable dehydration and loss of weight in some cases. 

Intake of vitamin D was on the whole far above the average require- 
ments. The vitamin was given soon after birth until the condition was recog- 
nized. Intake varied from 200 to 8800 I. U. per day. Twenty-eight of the 
infants received over 1000 units, twelve over 2000, three over 4000, and 
eight under 1000 units. In two cases there was no history of vitamin D 
intake either as such or in the milk. It may be significant that 27 of the 38 
infants received the vitamin as vitamin D£. The infants who had received 
in part vitamin Dj had never been given more than 400 units. 

Few abnormalities were noted on physical examination. Perhaps the 
most important finding was the presence of a certain amount of wasting and 
of slight dehydration. The infants were apathetic but not irritable, the lips 



14 Medical News Letter, Vol. 33, No. 4 



were dry, the eyes were slightly sunken, and the muscle tone and tissue 
turgor were generally poor. These manifestations were seldom, if ever, 
severe enough to cause alarm. The abdomen tended to be scaphoid, and 
scybalous masses in the colon were easily palpable. 

Fever was not a feature, and infection other than that found in the 
urinary tract was uncommon. Eleven of the 38 infants had mild pyuria which 
was peculiarly resistant to treatment and tended to recur with a different 
causal organism. 

The severity of the signs and symptoms bore no relationship to the 
level of the serum calcium, nor did improvement necessarily take place 
when the serum calcium returned to normal. Indeed, it was noted that 
improvement might be delayed several weeks; if treatment is omitted too 
soon, the serum calcium level might become elevated again within a week 
or 10 days. 

The clinical picture was such that a provisional diagnosis of hypercal- 
cemia was often made in the outpatient department to be confirmed later by 
the finding of a serum calcium of over 1Z mg. per 100 ml. For a period, 
routine serum calcium estimations were made on all infants under one year 
of age admitted to the wards and a few unsuspected cases were found. 

Of the known causes of hypercalcemia, only the milk and alkali syn- 
drome and hypervitaminosis D need be considered. 

Forfar and associates suggested that there is a disturbance of choles- 
terol metabolism probably induced by infection. They found that the serum 
citrate level and the urinary output of citrate were both low during the 
active stage of the disease — a finding in contrast to the high figures usually 
obtained in hypervitaminosis D. They also noted that a low calcium intake 
induced a negative calcium balance and lowered the level of the serum cal- 
cium to normal without necessarily causing clinical improvement. 

Creery suggested a parallel with the milk and alkali syndrome des- 
cribed by Cope as occurring in patients with peptic ulcer on treatment with 
large intakes of milk and alkali and in whom the serum calcium, serum 
phosphorus, and blood urea are raised. Alkalosis may occur in infants 
with high intestinal obstruction (pyloric stenosis) or in older children with 
poor renal function following alkali admir.istration, and although the total 
serum calcium may rise slightly — as it does in gastric tetany — lev.els of 
12 mg. pex" 100 ml. are seldom found. 

Broadly speaking, the clinical picture of idiopathic hypercalcemia, t 
namely, anorexia, listlessness, constipation, and thirst with polyuria and 
slight dehydration, is similar to that ascribed to hypervitaminosis D. Like- 
wise, the biochemical findings are in keeping with such a diagnosis, a 
raised serum calcium and serum phosphorus and an increased excretion 
of phosphorus in the urine. The latter finding is present even when the 
serum calcium has returned to normal following the use of cortisone or low 
calcium milk and can be taken as evidence that homeostasis is not achieved 



Medical News Letter, Vol. 33, No. 4 15 



at once; it provides an explanation of the persistence of the clinical picture 
in the presence of a normal serum calcium content. 

The clinical picture of idiopathic hypercalcemia is described and 
evidence adduced that the etiologic factor concerned is the intake of vita- 
min D. The hypercalcemia is due to excessive intake, the impurities which 
vitamin D£ contains, or to hypersensitivity of the" infant. (Graham, S. , 
Idiopathic Hypercalcemia: Postgrad. Med. , British Commonwealth Issue, 
25: 67-72, January 1959) 

>jc $ 3JE 1fc sjt a(t 
Pituitrin for Ble eding Esophageal Varic es 

The therapy of the acute bleeding from esophageal varices has had 
numerous and varied approaches both surgical and nonsurgical in nature. 
The multiplicity of approaches which have been suggested indicates a lack 
of satisfaction with any single regimen and the consequent need for thera- 
peutic additions and improvements. Surgical Pituitrin or Pitressin admin- 
istered intravenously to experimental animals resulted in a temporary fall 
in portal pressure and, therefore, their use was proposed as a supplement 
to other methods of controlling hemorrhage from esophageal varices. 
Clinical experience suggests that these drugs are very effective in the con- 
trol of the acute bleeding episode and that they are also helpful in diminish- 
ing the marked bleeding encountered during transesophageal ligation of 
varices. In addition to the beneficial effects noted clinically, direct meas- 
urements of portal vein pressures in patients with portal hypertension have 
demonstrated that intravenous surgical Pituitrin re suits in a significant 
decrease in portal pressure under these conditions. 

Intravenous surgical Pituitrin or Pitressin was used therapeutically 
in 1 1 patients with acutely bleeding esophageal varices. The estimated 
blood loss p.ior to institution of therapy varied between 25 and 1000 cc. 
Ten of these patients were alcoholic cirrhotics. The other patient's varices 
were secondary to thrombosis and cavernomatous transformation of the por- 
tal vein. In all instances, the presence of varices was confirmed by eso- 
phagogram or esophagoscopy. 

In a group of 9 patients, 25 distinct episodes of acute bleeding were 
treated with prompt control 22 times. The gastric aspirate cleared 5 to 20 
minutes after the completion of intravenous Pituitrin or Pitressin. The vital 
signs and microhematocrit determinations showed stabilization and later 
improvement with transfusion. In several instances, bleeding recurred 
after an interval of quiescence ranging from 6 hours to several days and 
Pituitrin was used to control the second and other subsequent episodes. 

The management of acutely bleeding esophageal varices remains a 
difficult problem. In the patient with significant liver dysfunction — especially 



16 Medical News Letter, Vol. 33, No. 4 



with jaundice — anesthesia and surgery frequently precipitate hepatic failure 
and coma. Nevertheless, immediate surgical attacks, either by transeso- 
phageal ligation or portacaval anastomosis, have been proposed in view of 
the unsuccessful results associated with the conservative regimen. Although 
the injection of bleeding esophageal varices with sclerosing solutions has 
enjoyed sporadic popularity, the use of balloon tamponade has been the 
notioperative method usually adopted for the control of esophageal hemor- 
rhage. Aspiration, asphyxiation due to regurgitation of the inflated eso- 
phageal balloon with consequent obstruction of the airway, and ulceration 
at the site of tamponade have all been reported and experienced in a signi- 
ficant number of instances. An appreciable number of patients have com- 
plained of marked discomfort associated with esophageal tamponade and, 
because sedation is to be avoided with hepatic insufficiency, the problem 
is greatly intensified. 

The lack of complete satisfaction with the tamponade approach and 
the desire to avoid extensive surgery in a patient with hepatic insufficiency 
prompted clinical investigation of a method which would intrinsically lower 
portal venous pressure. Intravenous surgical Pituitrin or Pitressin rapidly 
decreases portal hypertension and reduces bleeding from esophageal varices 
with consistent effectiveness. Subsequent to reduction of portal pressure, 
the turgid veins collapse as evidenced by esophagoscopy and direct inspec- 
tion during esophagotomy for transesophageal ligation. The edges of the 
bleeding site can coapt, an hemostatic thrombus can form, and the patient 
may be tided over for a period during which he is prepared for definitive 
surgery with a regimen directed at restoring liver compensation. 

Surgical Pituitrin and Pitressin are worthwhile additions to the therapy 
of bleeding varices. Direct portal venous pressure measurements in patients 
with esophageal varices have demonstrated that intravenously administered 
surgical Pituitrin results in a rapid and marked decrease in portal pressure 
equivalent to the level achieved by portacaval shunt. The drugs have proved 
effective in the control of acutely bleeding esophageal varices and have been 
helpful in facilitating transesophageal ligation of bleeding varices. It is 
recommended that an intravenous surgical Pituitrin or Pitressin regimen 
be given an initial trial in the control of bleeding in view of the distinct 
advantages over balloon tamponade. (Schwartz, S. I. , et al. , The Use of 
Intravenous Pituitrin in Treatment of Bleeding Esophageal Varices: Surgery 
45: 72-78, January 1959) 

>[e sji >[< sjc sje 4t 

Please forward requests for change of address for the News Letter to: 
Commanding Officer, U. S. Naval Medical School, National Naval Medical 
Center, Bethesda 14, Md. , giving full name, rank, corps, and old and new 

addresses. 



Medical News Letter, Vol. 33, No. 4 17 



Strangulated Femoral Hernia 

A femoral hernia is more likely to undergo acute incarceration and 
subsequent strangulation than any other common hernia. Strangulation may 
occur at any time and constitutes an urgent surgical emergency. It is esti- 
mated that strangulation occurs in approximately 10% of all femoral hernias. 
Acute incarceration occurs more frequently in this type of hernia because 
the small femoral ring through which the herniation occurs is more rigid 
and because herniation through the defect occurs in a more vertical or 
downward direction. It is this latter factor, uniquely characteristic of the 
femoral canal hernia which contributes to the difficulty in reducing it. Once 
entrapped, the contents of the sac are inhibited in returning to the abdomen 
by the well defined and narrowed margins of the hernia defect. When inter- 
ference with circulation occurs, the strangulation affects the contents of 
the sac and the tissues which make up the sac — the parietal peritoneum, 
properitoneal tissue, and transversalis fascia. 

The sex incidence of all studies on all femoral hernia favors the 
female. In the present study of 170 acutely incarcerated hernias, 68% were 
females and 32% were males. There were twice as many males treated in 
the first half of this period of the study as in the latter half. Out of the total 
hospital admissions for acute femoral herniation, there were 14 Negro females 
and 2 Negro males. Thus, Negroes made up 5% of the total patients in this 
study. Shelby recorded a 2. 3% incidence of Negro patients. Because the 
average Negro census during the years 1941 to 1955 averaged 22%, it appears 
that femoral hernias may occur with relatively less frequency in the Negro 
race. As in the case of inguinal hernias, femoral hernias occur on the right 
side twice as frequently as on the left. 

In general, the acutely strangulated hernia containing small bowel 
produces more pronounced symptoms indicative of mechanical intestinal 
obstruction. When structures other than small intestine are incarcerated 
and subsequently strangulated, the symptoms and signs are often less dra- 
matic. The usual history is that of a sudden onset of pain frequently noted 
in the region of a previously reducible hernia which has become firm and 
irreducible. The abdominal pain is poorly localized at first and later 
becomes cramping in nature. The onset of incarceration is associated with 
increased exertion in approximately one -third of the cases. However, many 
cases occur with no unusual effort. 

Vomiting occurs early and is a prominent symptom. A mass in the 
femoral region is the most important single physical finding. Many times 
the mass is completely overlooked and in other instances its significance is 
often misinterpreted. Acute strangulation of a femoral hernia is a common 
cause of acute intestinal obstruction among patients more than 50 years of 
age. If the diagnosis is thought of and properly examined for, the condition 
is usually not difficult to diagnose. 



18 Medical News Letter, Vol. 33, No. 4 



The classical symptoms of intestinal obstruction are usually present 
in cases of strangulated femoral hernia. When intestinal colic associated 
with vomiting suggests a diagnosis of probably acute intestinal obstruction, 
hernial orifices should be carefully examined for the presence of a mass. 
With care, a differential diagnosis between a femoral hernia and an incar- 
cerated inguinal hernia can be made. The femoral hernia is palpable below 
and lateral to the pubic spine, while the inguinal hernia is found to lie 
superiorly and medially to the pubic spine. Frequently, the femoral hernia 
mass protrudes forward and upward to partly obscure the inguinal ligament. 

The present study on acutely incarcerated and strangulated femoral 
hernia was undertaken primarily to discover the results of treatment for 
this condition and the factors significantly effecting these results. Data 
from available clinical charts was tabulated by I. B.M. machine. Because 
of the mass of detailed data available with the use of I. B. M. tabulation, 
only brief comments are made regarding the data presented on mortality. 
Tables summarize the data succinctly. 

There was a total of 42 postoperative complications in 37 cases. The 
wound infection incidence was 6. 6% with 11 patients manifesting some degree 
of suppuration in operative incisions. The majority of these were noted in 
patients who had had excision of gangrenous small bowel. 

There appeared to be no relationship between prolonged operating 
intervals and an increase in the number of postoperative complications, 
but a definite relation was seen — as would be expected — among those cases 
with other associated diseases. A Table lists the more severe postopera- 
tive complications and gives the number of deaths attributable to each of 
these. Shock accounted for the largest number of postoperative deaths, while 
atelectasis with pneumonia and shock occurred as postoperative complica- 
tions most frequently and were seen in 24 instances. Congestive heart fail- 
ure, renal failure, cerebral vascular accidents, pulmonary embolism, 
coronary occlusion, phlebothrombosis, and gastrointestinal hemorrhage 
were problems in other postoperative cases. 

The seriousness of delayed or incorrect diagnosis is emphasized. 
The influence of age, sex, presence of other associated diseases, electro- 
lyte imbalance, duration of operative time, sac contents, and the side 
affected, on mortality is summarized. An adequate surgical approach is 
important and the excellence of the Cheatle-Henry extraperitoneal, retro- 
pubic operation is described. 

The over all mortality for this group was 13%. The male operative 
mortality was 20% while that of female patients was only 10%. Results of 
this group are compared to other reports. There were 35 bowel resections 
for gangrenous small bowel with nine deaths, a 26% mortality. No deaths 
were due to faulty anastomoses. An elective repair of all femoral hernias 
is advisable. (Rogers, F. A. , Strangulated Femoral Hernia - A Review of 
170 Cases: Ann. Surg., 149:9-19, January 1959) 



Medical News Letter, Vol. 33, No. 4 19 

" To Comfort Always" 

"To cure sometimes, to relieve often, to comfort always"; this quo- 
tation appears on the statue erected to the honor of Francis Trudeau at 
Saranac Lake. These few words actually summarize the physician's 
function in his practice of medicine. 

In this age of antibiotics, increasing specialization, and laboratory 
medicine, many of us tend to lose sight of our primary function in the care 
of patients. Regardless of how specific our diagnostic and therapeutic aids 
may become, we still must be willing and able to communicate effectively 
with our patients if we are to function well in the healing of the sick. 

Scientific knowledge has become an indispensable tool of the modern 
physician, and no one can be a good doctor today without competent and 
adequate scientific training. But more is needed to practice good medicine, 
which has remained an art while becoming a science. It is today a far- 
advanced science. But in addition — it has always been and will always be — 
an art. The secret of healing derives not only from knowledge, but from 
the human qualities of the healer as well. That physicians of the sixth 
decade of the twentieth century should have to discover man has a psyche 
as well as a soma is a travesty on modern medicine. In spite of this appar- 
ent "new discovery, " many of us still give only lip service to the emotional 
aspects of the problems of the patient. 

There are plenty of capable physicians, the need is for physicians 
who are nice to people. To some, this art seems to be inherent; to others, 
it has to be a conscious and planned part of their behavior. We frequently 
look askance at those members of our profession who have developed the 
art of being nice to people to such a high degree while allowing their sci- 
entific knowledge to deteriorate. These individuals invariably have highly 
successful practices much to the dismay and chagrin of their more scien- 
tifically oriented colleagues. The" patients of these physicians are unusually 
loyal. Because of our disdain for the professional qualifications of this type 
of physician, many of us swing rather far in the opposite direction. We 
sometimes erroneously associate the quality of being "too nice" to our 
patients with professional mediocrity. Nothing could be farther from the 
truth. 

Indeed, one gets the impression when talking with an occasional con- 
sultant that he dare not be "too nice" to the patient lest his standing as a 
consultant be questioned. These individuals, fortunately, are rare. The 
fact remains that in our training in scientific medicine the art of being nice 
to patients is insufficiently stressed. It seems ironic that as our scientific 
knowledge is advancing at such a rapid rate our appreciation of the very 
basic art of medicine is diminishing with alarming rapidity. Are our view- 
points too limited to encompass the whole picture? Let us not miss the boat 
in our zeal for more scientific understanding of disease and lose the very 



20 Medical News Letter, Vol. 33, No. 4 

foundation of medical practice — patient understanding. With this quality, 
the practice of medicine as we know it can withstand any storm. Without 
it, patients and doctors alike will have a hard road ahead, " (Editorial: 
Journal of the Medical Association of Georgia, November 1958. Reprinted 
inAMANews, December 29, 1958) 

% ;}: s[c ^t Hz %; 

From the Note Book 



1. Rear Admiral B. W. Hogan MC USN, the Surgeon General, attended the 
Board of Trustees' Meeting of the American Hospital Association, Chicago, 
111., 2-3 February 1959. (TIO, BuMed) 

2. Rear Admiral E. C. Kenney MC USN, and Captains E. V. Jobe and 
M. W. Arnold MC USN represented the Bureau of Medicine and Surgery 
at the 55th Annual Congress on Medical Education and Licensure held in 
Chicago on 7 - 10 February 1959. (TIO, BuMed) 

3. Captain H. A. Weiss MC USN has been elected to Fellowship in the 
American College of Physicians, and Commander H. A. Baker MC USN 

has been elected to Fellowship in the American College of Surgeons. (BuMed) 

4. About 438 million acute illnesses involving either restricted activity or 
medical attention or both occurred among the American people during the 
year ending June 30, 1958. The number of such illnesses averaged 2. 6 
for every person in the population. (PHS, HEW) 

5. Prolonged low back disability in 100 cases treated at a rehabilitation 
center were studied in the hope of revealing useful information aiding in the 
management of such patients. These represented a hard core of industrial 
invalids refractory to prolonged medical and surgical treatment. The mech- 
anism of psychogenic back pain is discussed and suggestions made for 
physical, pharmacological, psychological, and vocational treatment. (Indust. 
Med. SiSurg., January 1959; E. E. Gordon, M. D. ) 

£>■ Acute ataxia in children is thought to be symptomatic of various infec- 
tions or toxic encephalopathies which affect the cerebellum predominantly. 
Observations made in 15 cases suggest mumps, poliomyelitis, influenza, 
varicella, and intoxication from insecticides as possible etiologies. It has 
been reported in association with rubeola, rubella, smallpox, scarlet fever, 
typhoid, infectious mononucleosis, diphtheria, and drug intoxication. The 
prognosis for complete recovery is good. (A. M. A. J. Bis. Child., January 
1959; G. M. Lasater, M. D. , J. T. Jabbour, M. D. ) 



Medical News Letter, Vol. 33, No. 4 21 



7. Aspiration pneumonia is a pulmonary problem that may present a great 
deal of diagnostic difficulty and is frequently neglected in the differential 
diagnosis of pulmonary lesions. Aspiration pneumonia may result from : 
aspiration of oils-lipoid; food and gastric secretions; foreign bodies; and 
infected materials. (Dis. Chest, January 1959; I. R. Besman, M. D. , 

H. A. Lyons, M. D. ) 

8. Twenty-three cases of fungus and other granulomatous diseases of the 
lung are reviewed. Skin tests, serologic data, cultures and smears, exam- 
ination of biopsy material, geographic data, and bronchoscopy are all val- 
uable adjuncts in the diagnosis of the indeterminate pulmonary lesion. 
Deficiencies and pitfalls with these aids are enumerated and stressed. (Arch. 
Int. Med., January 1959; J.H. Sands. M. D. et al. ) 

9. Penicillin reactions have produced over 1000 deaths in this country. 
Reactions are increasing steadily in frequency and severity. This article 
reviews the subject and presents 4 case reports proving for the first time 
that penicillin contaminating milk causes allergic reactions. (Arch. Dermat. , 
January 1959; M. C. Zimmerman, M. D. ) 

10. In many cases of ocular palsy due to head injury, spontaneous recovery 
occurs, but in others there remains a constant deviation of the visual axes 
associated with diplopia. This article is based on experience of treating 

70 patients with ocular palsy due to head injury during an 8-year period. 
(Postgrad. Med. J., January 1959; T. Keith Lyle) 

11. Fifteen cases of carcinoma of the breast treated by operation with skin 
grafting were given postoperative radiation in full therapeutic doses, the 
graft in part or in full being included in the treatment field. The tolerance 
of skin grafts to radiation therapy approximates that of normal skin. (Ann. 
Surg., January 1959; R. W. Cram. M. D. et al. ) 

12. During the past year, the Surgeon General of the Public Health Service, 
Department of Health, Education, and "Welfare, awarded more than $1,000,000 
in grants and fellowships for nursing research. These funds will support 15 
research studies and enable 12 nurses with bachelors degrees to train for 
research careers. (PHS, HEW) 

13. This report discusses 3 types of pulmonary granuloma: sarcoidosis, 
histoplasmosis, and noninfectious necrotizing granulomatosis. An attempt 
is made to select material and to emphasize aspects of these diseases which 
are not familiar to many roentgenologists. (Am. J. Roentgenol., February 

1959; B. Felson, M. D. ) 

* ;ji # # * # 



22 Medical News Letter, Vol. 33, No, 4 



Right to Drive 

More than four human lives are sacrificed on the roads of America 
every hour. Traffic fatalities are a major cause of death in the United 
States. Frankly, the problem threatens to become far worse unless the 
people readjust their thinking and adopt a more realistic attitude toward 
the citizen who — although law abiding in all other respects — repeatedly 
violates traffic regulations. 

In terms of the grief and suffering which he causes, the careless, 
indifferent or irresponsible motorist is as great a threat to this country 
as the most vicious criminal gunman. 

Yet disrespect for traffic regulations has become so commonplace 
throughout the United States today that in the minds of many motorists it is 
fashionable to exceed the speed limit, to drive through stop signs, to pass 
other cars on hills and to "run" a traffic light if no police cars are in sight. 
Reputable citizens — persons who would never think of committing other types 
of violations — run the gamut of traffic offenses without suffering the slightest 
pangs of conscience. 

Loud protests have been raised against the use of radar to detect speed- 
ers and, thereby, to make the roads safer for all. Police officers who stop 
violaters are sneered at and subjected to insults. Many offenders complain 
about the "inconvenience" of having to appear in traffic court. Warnings, 
pleas, and educational programs have made the least impression where the 
need for them has been the greatest possible. 

The time has come for the American people to stop tolerating the 
arrogant disrespectful attitude which so many motorists openly display toward 
the traffic codes. Drivers who prove by their own actions that they constitute 
a menace to themselves and others must be denied the privilege of operating 
motor vehicles. 

In areas where the existing laws are inadequate to meet the problem, 
new and more realistic traffic codes should be adopted. Motorists who are 
guilty of repeated offenses, as well as those who have intentionally placed 
the lives of other citizens in jeopardy, must be treated as the public menaces 
they are. Whenever it is in the public interest to do so, maximum fines and 
long jail sentences should be imposed upon offenders. 

Each year, traffic accidents claim thousands of American lives. The 
senseless slaughter and crippling of human beings on the roads have reached 
staggering proportions. This problem must be met immediately with forceful, 
positive action. 

The price of failure has become far too great— more than four human 
lives per hour. (J. Edgar Hoover, Home and Highway: Military Medicine, 
124 : 66, January 1959) 

^ ^ * ^< * ^ 



Medical News Letter, Vol. 33, No. 4 23 



Anesthetic Difficulties 



Occasional reports of difficulties with anesthetics are received by 
the Bureau of Medicine and Surgery, primarily from ships and small sta- 
tions where a qualified anesthesiologist is not available. Spinal anesthesia 
is the type most commonly utilized in most emergency surgical procedures 
aboard ship and at small stations. 

Procaine hydrochloride in the dosage of 150 mg. is usually satisfac- 
tory for one hour of good spinal anesthesia, but may last only thirty-to forty- 
five minutes in some young muscular individuals. 

Pontocaine hydrochloride (tetracaine hydrochloride) in the dosage of 
10 to 12 mg. , when diluted with 5 to 10% dextrose solution will give one and 
one -half to two hours of good spinal anesthesia, 

Pontocaine hydrochloride (tetracaine hydrochloride) is usually preferred 
to procaine hydrochloride as the anesthetic agent of choice for spinal anesthe- 
sia if anesthesia of longer than thirty to forty-five minutes is required to per- 
from surgical procedures aboard ship and at small stations where a qualified 
anesthesiologist is not available. 

When spinal anesthesia is no longer adequate to perform surgery at 
small stations and aboard ship, open drop ether is the anesthetic agent of 
choice in the hands of personnel other than an experienced anesthesiologist, 
even though the ether may vaporize so rapidly in warm climates that it may 
be very difficult to maintain adequate anesthesia in an adult patient. This 
difficulty may be minimized to some extent by using the semi-open technique 
for drop ether. The technique is the same as for open drop ether with the 
exception that a towel is wrapped about the ether mask in a chimney-like 
fashion. Some degree of rebreathing is then instituted. This permits a 
greater concentration of ether to be inhaled than by the open method, 

(ProfDiv, BuMed) 

& $ $ $ iff %t 

Board Certifications 

American Board of Internal Medicine 
CDR Herbert L. Walter MC USN 

American Board of Neurological Surgery 

LCDE Benjamin L. Crue, Jr. MC USN 

American Board of Pathology 

LT Laudie E. McHenry, Jr. MC USN 



24 Medical News Letter, Vol. 33, No. 4 

American Board o f Radiolog y 

LT Ronald W. Glover MC USN 

LT Robert Licht MC USNR (Active) 

LT William O. Pischnotte MC USN (Nuclear Medicine) 

LCDR Alfred E. Rawl, Jr. MC USN 

American College of Surgeons 

CAPT Herman F. Burkwall MC USN 

}}; ijc : If. ■'■: :^i :'<; 

Recent Research Reports 
Naval Dental Research Fa cility, NTC, Bainbridge, Md. 

1. Survey of Dental Health of the Naval Recruit. XI, Relation of the Formal 
Education of the Recruit's Father and Mother. NM 75 01 26. 04, 15 November 
1958 

2. Survey of Dental Health. XII. Relation of Brothers and Sisters. NM 75 
01 26.04, 30 November 1958. 

3. Survey of Dental Health. XIII. Relation of Opinions toward Dentistry. 
NM 75 01 26.04, 15 December 1958. 

Naval Medical Research Institute, NNMC, Bethesda, Md. 

1. Polynucleotides VII: The Interaction of Polyriboadenylic and Polyribo- 
uridylic Acids. NM 02 01 00.01.07, 21 August 1958. 

2. Inhibition of Polynucleotide Phosphorylase through the Formation of 
Complexes between Acridine Orange and Polynucleotides. NM 02 01 00.01.06, 
5 September 1958. 

3. Free Energy Changes of the Glutaminase Reaction and the Hydrolysis of 

the Terminal Pyrophosphate Bond of Adenosine Triphosphate. NM 02 05 00. 04.01, 
9 September 1958. 

4. Mic restructure of the Human Tooth. B. Investigation of the Initial Enamel 
Lesion by Polarization;, Fluorescence, and Micro radiographic Techniques. 
NM 75 01 30. 02. 01, 12 September 1958. 

5. Enthalpies of Hydrolysis of Glutamine and Asparagine and of Ionization 
of Glutamic and Aspartic Acids, NM 02 05 30. 04. 02, 22 September 1958. 

6. Report of Project Strato-Lab; A Study of Changes in Human Physiology 
Produced by Flights into the Stratosphere. Memorandum Report 58-7 related 
to NM 18 01 00.01, 22 September 1958. 

7. Relationship of Oxygen Debt to Blood Lactate and Pyruvate in Exercised 
Dogs. NM 004 006. 04. 01, 3 October 1958. 



Medical News Letter, Vol. 33, No. 4 25 



8. Relation. ship of Oxygen Debt to Blood Lactate and Pyruvate in Respiratory 
Hypoxia. NM 004 006. 04. 02, 3 October 1958. 

1 c 

9. Interpretation of Urinary N 1 -Excretion Data Following Administration 
of an N^-Labeled Amino Acid. Report No. 3, NM 007 009, 3 October 1958. 

10. Pattern of Nl5_Excretion in Man Following Administration of N* - 
Labeled L- Phenylalanine. Report No. 2, NM 007 009, 3 October 1958. 

11. Proteolytic Enzymes as Probes of the Secondary Structure of Fibrous 
Proteins. NM 01 01 00.02.08, 23 October 1958. 

12. Preparation of Large Intact Unsupported Evaporated Films. NM 71 01 00 
.07.01, 23 October 1958. 

Naval Medical Research Unit No. 3, Cairo, Egypt 

1. Cardiopulmonary Studies in Schistosomiasis. Report No. 5, The Clinical 
Aspects of Schistosomal Cor Pulmonale, NM 72 01 03. 4. 05, June 1958. 

2. Bilharzial Bladder Neck Obstruction. NM 52 02 03.4.01, July 1958. 

Naval School of Aviation Medicine, Pensacola, Fla. 



1. Auditory and Non-Auditory Effects of High Intensity Noise. Subtask No. 1, 
Report No. 7, NM 13 01 99, 2 June 1958. 

2. Massed and Distributed Practice in Learning to Track a Moving Target. 
Subtask No. 6, Report No. 6, NM 14 01 11, 5 September 1958. 

3. Personal Influence as a Factor in Contract Decisions, Subtask No. 1, 
Report No. 17, NM 16 01 11, 9 September 1958. 

Naval Medical Research Unit No. 2, Taipei, Taiwan 

1. Titration of Smallpox Vaccines from Ten Countries Sent to East Pakistan 
during the 1958 Smallpox Epidemic. NM 52 11 02.4. 1, 18 August 1958. 

2. Recurrence of Asian Variant Influenza in the Far East. Report of 1958 
Epidemic in U. S. Marines on Okinawa. NM 52 05 02. 4. 1, 16 October 1958. 

****** 
BUMED INSTRUCTION 6260. 6A 14 January 1959 

From: Chief, Bureau of Medicine and Surgery 

To: All Ships and Stations Having Medical Corps Personnel Assigned 

Subj : Hearing Conservation Program 

Encl: (1) Outline of Hearing Conservation Program 

(2) Selected Glossary of Applicable Terms 

(3) Bibliography 



26 Medical News Letter, Vol. 33, No. 4 



This instruction provides a guide for the establishment and implementation 
of uniform and effective hearing conservation programs throughout the Naval 
and Marine Corps Establishments. The basic objective of this program is 
to prevent hearing loss in personnel assigned to areas of high noise intensity. 
BuMed Instruction 6260. 6 is canceled. 

^s j|c 5^ s}: :Jc >;< 

BUMED INSTRUCTION 5711. 1 16 January 1959 

From: Chief, Bureau of Medicine and Surgery 

To: Ships and Stations Having Medical/Dental Personnel 

Subj: Procedures for disposition by medical installations of Allied patients 

End: (1) North Atlantic Treaty Organization Standardization Agreement 
No. 2061 

This instruction promulgates for information and compliance the North 
Atlantic Treaty Organization Standardization Agreement No. 2061. Previously 
issued regulations or directives in conflict with enclosure (1) are to be held 
in abeyance pending revision or specific cancellation. 

sje $ >|i ijc $ sis 

BUMED INSTRUCTION 6120. 11B 20 January 1959 

From: Chief, Bureau of Medicine and Surgery 

To: Ships and Stations Having a Flight Surgeon or Aviation Medical 

Examiner 

Subj: Physical qualification certification by the Federal Aviation Agency of 
Navy, Marine Corps, and Coast Guard personnel 

Ref: (a) Art. 15-59(5), ManMed 

This instruction is promulgated for guidance of flight surgeons and aviation 
medical examiners with respect to physical examinations and physical qual- 
ifications of candidates for Federal Aviation Agency Second Class Airman's 
Medical Certificates, the processing of the Report of Medical Examination, 
Standard Form 88, and the issuance of the aforementioned certificate. 
BuMed Instruction 6120. HA is canceled. 

* * $ * # * 



Medical News Letter, Vol. 3 3, No. 4 



27 



DENTAL 




SECTION 



New Endodontics Training Films 

The premier showing of Endodontics, a group of three training films 
produced by the staff of the U, S. Naval Dental School and the Audio -Visual 
Division of the U. S. Naval Medical School was held at the Naval Dental 
School, National Naval Medical Center, Bethesda, Md. , January 23, 1959. 

The showing was attended by members of the American Dental Assoc- 
iation's Council on Federal Dental Services, by high-ranking dental officers 
of the Armed Forces, representatives of other Government agencies) officials 
of local civilian dental organizations, and by others interested in dental and 
audio-visual education. 

The filming of Endodontics was undertaken as part of the Navy Dental 
Corps' continuing program to provide its Dental officers with current know- 
ledge on patient care and to promote dental education in general. The 16, mm. 
sound and color films, each of which runs for 45 minutes, cover (1) diagnosis 
and case selection, (2) biomechanical preparation, and (3) filling the root 
canal. 

The films, MN-8566ABC, Endodontics, A, Diagnosis and Case 
Selection, B, Biomechanical Preparation of the Root Canal, C, Filling the 
Root Canal, will be available under geneial distribution through District 
Film Libraries next summer. Until then, a limited number of films may 
be procured by letter request to Chief, Bureau of Medicine and Surgery 
(Code 3163), Navy Department, Washington 25, D. C. 

Letter of Commendation 



The Surgeon General, Rear Admiral B. W. Hogan, recently awarded 
a letter of commendation to Lieutenant Ethan C. Allen DC USN for ". . . 
outstanding work in providing dental care to alleviate pain for the approx- 
imately two hundred children in the Casa Materna Orphanage while attached 
to the U.S. Navy Support Activity, Naples, Italy, from July 1957 to January 
1959 . . . You unselfishly and with no thought of recompense or recognition 
devoted much of your off duty time to this humanitarian work. This willingness 



28 Medical News Letter, Vol. 33, No. 4 



to give of your professional skill to needy children who are unable to obtain 
care from other sources is in the highest tradition of the health professions 
and reflects credit on our Navy and on our country. " 

& sic «fc ft jfe Jfc 




RESERVE SECTION 






Tissue Bank Training Course 

A two -week Tissue Bank Training Course offered at the Naval Medical 
School, National Naval Medical Center, Bethesda, Md. , is now available 
to any eligible inactive Naval Reserve Medical officer. This training may 
commence on any Monday morning and provides orientation in the operation 
and administration of a tissue bank. 

The training includes: (a) indoctrination in the methods of tissue pro- 
curement; (b) storage and dispensing; (c) tissue culture; (d) tissue chemistry; 
(e) processing excised tissue and allied short and long-term research pro- 
jects in the tissue culture and tissue chemistry fields; (f) indoctrination in 
the medico-legal aspects of homotransplantation; (g) the procedure for obtain- 
ing permission for tissue donations; and (h) familiarization with the operation 
of the Tissue Bank Registry and all other administrative practices assoc- 
iated with tissue banking. 

Reserve Medical officers from the First, Third, Fourth, Fifth, Sixth, 
Eighth, and Ninth Naval Districts may attend this, course on a limited quota 
basis authorized by the Chief of Naval Personnel. Security clearance is not 
required. 

* ije $ $ 3fe $ 

Medical Military Training 

A two-week course in Medical Military Training beginning 9 March 
1959 will convene at the Naval Medical School, NNMC, Bethesda, Md. 

The first week will be devoted to Medical Aspects of Special Weapons 
and Radioactive Isotopes with particular reference to personnel casualties 
from atomic explosions. The second week will be devoted to professional 
topics of concern to military medicine including discussions on Reserve 
medical programs of the Armed Forces. As this course has new subjects, 



Medical News Letter, Vol. 33, No. 4 29 



new material, and has been revamped to bring it up to date, it is highly 
recommended that officers repeat this training in the event they have par- 
ticipated in previous classes. 

Naval Reserve Medical Department officer personnel from the First, 
Third, Fourth, Fifth, Sixth, Eighth, and Ninth Naval Districts may attend 
on a limited quota basis. No security clearance is required. 

5p ?JC Jj£ sfi 5JC *f 

Convening Dates for Pest Control Courses 

Two-Week Active Duty Training Course in Disease Vector Control 

New convening dates are listed below for the 14 -day AcDuTra course 
in Disease Vector Control, Vector Control Center, U. S. Naval Air Station, 
Jacksonville, Fla. The new schedule offers this course every other month 
instead of monthly with the exception of June and August when the course 
will be given twice during these two months. 

Convening Dates for Calendar Year 1959 

9 February through 20 February 

6 April through 17 April 
1 June through 1Z June 
15 June through 26 June 

3 August through 14 August 

17 August through 28 August 

5 October through 16 October 

7 December through 18 December 

This course is open to all Reserve personnel, both officer and enlisted. 

Four-Week Basic Course in Pest Control 

New convening dates are listed below for the basic course in Disease 
Vector and Economic Pest Prevention and Control. The new schedule extends 
the course from three weeks to four weeks and is offered every other month 
instead of quarterly. 



Convening Dates for Calendar Year 1959 



2 March through 27 March 

4 May through 29 May 

6 July through 31 July 

7 September through 2 October 

2 November through 28 November 



30 Medical News Letter, Vol. 33, No. 4 



The course is open to all active duty officer and enlisted personnel. 
Military civilian employees engaged in pest control activities are also 
eligible and are urged to attend. Billeting and messing facilities are avail- 
able at U. S. Naval Air Station, Jacksonville 12, Fla. , for both military and 
civilian personnel attending the course. 

Attendance quotas. Attendance quotas for these courses are allocated 
and may be requested by communicating directly with the Officer in Charge, 
Disease Vector Control Center, U.S. Naval Air Station, Jacksonville 12, Fla. 

% ^c jjc ;{s Jjt sjs 



AVIATION MEDICINE DIVISION 




Flash Blindness and Chorioretinal Burns 
Produced by Atomic Flash 

Two separate, although related, conditions may be produced by atomic 
flash. One is flash blindness, a temporary incapacitation produced by vis- 
ible light, and the other is retinal burn produced by a combination of visible 
and infrared light. Their implications from a disaster standpoint are quite 
different. 

Flash blindness is due to the bleaching of the retinal photosensitive 
chemicals by bright light. The duration of the incapacitation produced 
depends on the brightness of the items one must see after the flash is over. 
In daylight this is not a serious problem. The pupils will be smaller and 
will admit only l/50ch as much light as at night and the visual task will 
ordinarily be much brighter. There may be a temporary scotoma in the 
field of vision, but unless a burn is produced it will disappear and it is not 
visually incapacitating. At night, visual disability will exist up to half an 
hour if the source of illumination of the visual task is a moonless sky. Any 
increase in brightness of the visual task will reduce the disability time pro- 
portionately. The blink reflex is of little value in protection against flash 
blindness because of the extreme intensity of the light. The exact effect in 
any individual case will depend on the brightness to which the eye is exposed 
(whether looking toward the fireball or away), the reflectance of surfaces, 
and protection afforded by buildings, overhanging structures, hats or protec- 
tive filters. The reflectance of the background and of the atmosphere varies 



Medical News Letter, Vol. 33, No. 4 31 



so much that distances at which flash blindness can be expected will vary 
tremendously. With nominal bombs, at night, in the open, and with the 
subject facing the direction of the detonation, it can be expected at distances 
of over 35 miles. 

Effective filters to prevent flash blindness usually also prevent the 
individual from doing anything useful. This is true except for special fil- 
ters designed with sharp cutoffs to permit certain specialized visual tasks 
utilizing narrow bands of monochromatic light. If a period of warning is 
given, the individual can cover both eyes to prevent both flash blindness 
and retinal burns. If he must see during the warning period, a patch may 
be worn over one eye to protect the retinal adaptation in that eye even though 
the uncovered one is dazzled by the flash. The patch may then be placed over 
the eye with flash blindness so it can adapt and be protected in the event of a 
second flash later while the previously protected eye is used for seeing. 

The effect of flash blindness on implementation of civil defense plan- 
ning will depend on adequate warning, and on the success with which know- 
ledge of the condition has been previously imparted to civil defense personnel. 

Chorioretinal burns are a related phenomenon. Their production depends 
on the lens system of the eye forming an image of the fireball on the retina. 
The visible and near infrared light (400-1, 250mq) energy is absorbed by the 
retinal and choroidal pigment. The distance to which these can be produced 
depends on pupillary size, clarity of the atmosphere, and size of the bomb. 
They can be produced by a nominal bomb to distances over 35 miles when 
the air is clear. Again, so much energy is delivered before the blink reflex 
that it is not effective in preventing this lesion. Pupillary size is important, 
thus making this much more of a night-time than daytime hazard. The direc- 
tion of the visual axes is much more important than point of focus. While the 
latter has some effect on the area of the retinal image, it is not significant 
in attenuating the energy per unit area in it. Unless the image of the fireball 
is formed on the macular area, the permanent effect will be a scotoma in the 
peripheral field similar to that of the physiological blind spot. It differs in 
that it will be in the same position in both eyes, thus giving a true symme- 
trical binocular scotoma. This will not ordinarily be a serious visual defect. 
However, if it is imaged on the macula bilaterally, this will result in a 
permanent central scotoma with vision reduced to ZO/200 (peripheral acuity). 
This lesion can occur outside the danger zone of any other atomic effect 
except fall-out. 

Neither of these conditions requires civil defense planning for treat- 
ment. Recovery from flash blindness will take place in about half an hour. 
If the energy is high enough to produce a burn, it is not painful because the 
retina has no pain endings and it requires no dressing. In severe burns, 
it may be desirable to use steroids to reduce the inflammatory reaction and 
subsequent scarring of the retina, but no emergency treatment is required. 
The temporary effect of flash blindness is probably a much greater hazard 



3Z Medical News Letter, Vol. 33, No. 4 



to effective civil defense action than is the permanent burn. Civil defense 
efforts in regard to these conditions should be directed toward education 
to prevent flash blindness in at least one eye and the understanding that if 
it does occur, normal vision will return shortly. Such understanding may 
be helpful in the prevention of panic. (Guest Editorial, Brigadier General 
V.A. Byrnes, USAF (MC), J. A. M. A, , 168 : 6, 11 October 1958) 

Pulmonary Bone Marrow Embolism 
in Accident Reconstruction 

A search for pulmonary emboli may provide valuable information as 
to the timing of injuries relative to death. In so far as the significance of 
minor degrees of fat embolism is in some dispute while bone marrow embol- 
ism is generally agreed to arise from bone fracture, it was thought that the 
latter might provide more definite information than the former. 

One hundred and two aircraft accident fatalities who had sustained 
bone fracture have been examined for pulmonary bone marrow embolism. 
The incidence discovered was 40. 2% positive cases which is considerably 
higher than has previously been reported. Some cases were examined more 
thoroughly than others and many positive cases must have been missed as 
a result of sampling error. An analysis of the findings indicates that if 5 
blocks from the lungs are examined as a routine, the incidence of bone 
marrow embolism in aircraft accident cases approximates 60%. 

It is suggested that the general belief in the comparative rarity of 
bone marrow embolism stems from the examination of an inadequate amount 
of material. 

Bone marrow embolism is far less common in cases where 4 or more 
long bones are fractured; it is less common in cases where more than six 
ribs are fractured; and it is less common in the presence of skull fracture, 
the majority of such fractures being very severe in aircraft accidents. It 
is concluded that the absence of pulmonary bone marrow embolism is gen- 
erally associated either with sufficient trauma to produce widespread and 
instantaneous death of all components of the body or with injuries resulting 
in instantaneous paralysis or destruction of the cardiovascular system. 
The presence of emboli indicates that the subject had a functioning circula- 
tion after the body injury was sustained. 

Emboli can appear with great speed, 30% of "immediate" deaths being 
positive for bone marrow emboli. If life persists for a few minutes, the 
porportion of markedly positive cases increases. On survival for hours, 
emboli become increasingly difficult to find, but at about 2 to 5 hours may 
be replaced by marrow cell masses in the pulmonary veins. Fat embolism 
of the lungs appears even more rapidly after injury and, within minutes, 



Medical News Letter, Vol. 33, No. 4 33 



increase in amount similarly to bone marrow embolism. At a few hours, 
however, there is no corresponding fall off. Fat embolism of the lungs 
not only resolves far more slowly than bone marrow embolism, but may 
go on to be fatal. It is suggested that an analysis of pulmonary fat and 
bone marrow embolism may give useful confirmatory evidence as to the 
survival period after injury. 

These findings may well be applied in accident reconstruction and, 
as an example, deaths arising from normal and abnormal ejections are 
analyzed. 

In the former, which are generally low level escape attempts, a nor- 
mal body strikes the ground sustaining multiple severe injuries, often in- 
cluding cardiac rupture; bone marrow emboli would not be anticipated in 
such circumstances. In the latter, particularly when associated with spon- 
taneous seat firing, non-fatal bony injury commonly occurs before ground 
impact; the conditions are then ideal for the production of emboli. 

All spontaneous ejections in the series save for one exceptional case 
showed bone marrow emboli in the lungs. Of the premeditated fatal ejec- 
tions, all those negative for emboli were simple low level cases except 
one whose heart was penetrated during descent. Four uncomplicated low 
level cases were mildly positive for emboli, but all four were alive when 
found on the ground; in two other mildly positive cases, there was evidence 
of injury before or during ejection. No uncomplicated low level cases 
occurred in the markedly positive group which included three cases very 
liable to have fouled their seats during descent. A fourth case sustained 
a fractured spine at the time of ejection while the last was the only case 
in the series who died from pulmonary fat embolism. 

Therefore, it seems that it may be possible to differentiate normal 
from abnormal fatal ejection attempts according to whether or not pulmon- 
ary bone marrow embolism is present. 

The small number of cases comprising the series dictates that this 
article must be of an interim nature, reporting an impression only. It is 
suggested that further study should be undertaken to prove or disprove the 
hypotheses put forward. (Wing Commander J. K. Mason, RAF Institute 
of Pathology, Halton, England) 

****** 
Anthropometric Data 

Many flight surgeons participated in making anthropometric 
measurements on their pilots last spring. The data has now been reduced 
using a computer. The Air Crew Equipment Laboratory will further eval- 
uate the data and issue a U. S. Navy report on this subject. 



34 



Medical News Letter, Vol. 33, No. 4 



For the curious, here are some of the tabulations that have been made: 



WEIGHT 



OVERALL HEIGHT 



Mean: 167.55 (.17) 
Standard Deviation: 6.04 
Range: 118.00 - 228.00 
Coefficient of Variation: 
Size of Sample: 1300 



(.12) 

3.60 (.07) % 



PERCENTILE VALUES 



Mean: 70.20 (.13) 

Standard Deviation: 4.70 (.09) 

Range: 60.00 - 78.50 

Coefficient of Vari*tion: 6.70 (.13) % 

Size of Sample: 1293 

PERCENTILE VALUES 



% 


Pounds 


1 


126.9 


2 


131.3 


3 


133.7 


5 


137.6 


10 


143.9 


15 


148.1 


20 


151.9 


25 


155.3 


30 


157.8 


35 


160.5 


40 


163.4 


45 


165.6 


50 


167.8 


55 


170.0 


60 


172.0 


65 


174.0 


70 


176.5 


75 


179.4 


80 


182.4 


85 


186.5 


90 


190.4 


95 


197.9 


97 


202.7 


98 


205.5 


99 


212.1 



% 


Inches 


1 


64.9 


2 


65.7 


3 


65.9 


5 


66.3 


10 


67.2 


15 


67.8 


20 


68.2 


25 


68.7 


30 


69.0 


35 


69.3 


40 


69.7 


45 


69.9 


50 


70.2 


55 


70.5 


60 


70.8 


65 


71.1 


70 


71.4 


75 


71.8 


80 


72.1 


85 


72.5 


90 


73.2 


95 


74.1 


97 


74.8 


98 


75.1 


99 


75.9 



SITTING HEIGHT 



SHOULDER HEIGHT 



Mean: 36.01 (.16) 

Standard of Deviation: 5.80 (.11) 

Range: 31,25 - 41.00 

Coefficient of Variation: 16.10 (.32) % 

Size of Sample: 1294 



Mean: 24.63 (.16) 

Standard Deviation: 5.58 (.11) 

Range: 20.50 - 33.00 

Coefficient of Variation: 22.65 (.47) % 

Size of Sample: 1293 



Medical News Letter, Vol. 33, No. 4 



35 



PERCENTILE VALUES 



PERCENTILE VALUES 



% 


Inches 


1 


32.4 


2 


32.9 


3 


33.1 


5 


33.5 


10 


34.2 


IS 


34.6 


20 


34.9 


25 


35.1 


30 


35.3 


35 


35.5 


40 


35.6 


45 


35.9 


50 


36.0 


55 


36.1 


60 


36.4 


65 


36.5 


70 


36.8 


75 


37.0 


80 


37.1 


85 


37.5 


£0 


37.9 


£5 


38.3 


67 


38.9 


93 


3S.1 


BE 


39.8 




ARM REACH 



% 


Inches 


1 


21.9 


2 


22.1 


3 


22.4 


5 


22.6 


10 


23.0 


15 


23.3 


20 


23.5 


25 


23.7 


30 


23.9 


35 


24.0 


40 


24.2 


45 


24.4 


50 


24.5 


55 


24.7 


60 


24.9 


65 


25.0 


70 


25.1 


75 


25.4 


80 


25.6 


85 


25.9 


SO 


26.3 


95 


27.0 


97 


27,3 


98 


27.6 


9S 


28.9 


■ 


LEG LENGTH 



Mean: 30.61 (.17) 

Standard Deviation: 6.07 (.12) 

Range: 22.25 - 41.00 

Coefficient of Variation: 19.82 (.40) % 

Size of Sample: 1295 



Mean: 42.46 (.14) 

Standard Deviation: 5.17 (.10) 

Range: 35.00 - 57.75 

Coefficient of Variation: 12.18 (.24) % 

Size of Sample: 1291 



PERCENTILE VALUES 



PERCENTILE VALUES 



% 


Inches 


1 


24.4 


2 


24.7 


3 


24.8 


5 


25,0 


10 


25.5 


15 


26.1 


20 


27.7 


25 


28 .9 



% 


Inches 


1 


36.8 


2 


37 .'3 


3 


37.8 


5 


38.3 


10 


3S.3 


15 


3S.8 


20 


39.8 


25 


40.3 



36 



Medical News Letter, Vol. 33, No. 4 



Percentile Values (continued) 



Percentile Values (continued) 



30 


2S.8 


35 


30.2 


40 


30.7 


45 


31.0 


50 


31.3 


55 


31.6 


60 


31. & 


65 


32.2 


70 


32.5 


75 


32.8 


SO 


33.1 


85 


33.4 


SO 


33. . 


S5 


34.3 


&7 


35.3 


GS 


35.6 


99 


36.1 





30 


40.8 




35 


41.3 




40 


41.3 




45 


41.8 




50 


42.3 




55 


42.3 




GO 


42.8 




65 


43.3 




70 


43.8 




75 


43.8 




60 


44.3 




85 


44.8 




ivO 


45.3 




&5 


46.3 




&7 


47.3 




ts 


47.8 




SS 


48.8 


~[i sje s{< 





Utilization of Squadron Flight Surgeons 



A recent report of an air group flight surgeon on the death of one of 
his pilots intimated that if that flight surgeon had not been required to remain 
on the flight deck during all flight operations he could have discovered that 
the deceased pilot was suffering from flight fatigue before his fatal flight 
was initiated. 

It is difficult to prove or disprove the above hypothesis, but the exis- 
tence of such a concept focuses attention to the sagacity of assuring free- 
dom of action by the squadron flight surgeon as is necessary. 

It is alleged that on some ships a flight surgeon is required to be pres- 
ent on the flight deck during all flight operations and must not leave the flight 
deck during such operations unless relieved by a doctor. No instruction to 
this effect has ever been published by ComNavAirLant or by any higher 
authority. If any such order is in effect on any NavAirLant ship, consider- 
ation of revision of such order is recommended. 

AirLant/AirPac CV Medical Instruction 5400. 1, chapter 1, section 3, 
places the responsibility of direction of an embarked flight surgeon upon the 
medical officer of the ship. Therefore, it would be wise for each carrier 
medical officer to so write his standing orders as to avoid any rigid instruc- 
tion requiring the squadron flight surgeon to be on the flight deck during 
ALL, flight operations. This would give the flight surgeon freedom to be at 
such locality as to permit him to "Determine by close observation and appro- 
priate clinical investigation the physical and psychological fitness of flight 
personnel. " 



Medical News Letter, Vol. 33, No. 4 37 



The flight surgeon can contribute much to aviation safety by his pres- 
ence on the flight deck at flight quarters and at other times. Indeed, that 
area is his usual station for General Quarters. However, during flight 
quarters it may be wise for the flight surgeon to be in the ready room where 
pilots for the next launch are being briefed iind are suiting up. He might 
wish to make a last minute check on the physical condition of a specific 
pilot. He may be needed in the sick bay for surgery or emergency care. 
Finally, as often occurs on CVS carriers, flight operations can extend over 
many hours; it might be wise to have the flight surgeon rest and leave the 
first aid duties of the flight deck to a well trained hospitalman. Severe 
injuries usually require examination, electrolyte replacement, transfusion, 
anesthesia, and surgery. The number of medical officers on a carrier is 
limited. Is it wise to so wear down a doctor by having him stand extended 
first aid watches on the flight deck as to make him ineffective when his 
services as a graduate of medicine are sorely needed? It is hard to con- 
ceive of any therapy other than first aid which could best be performed by 
a doctor on the flight deck. Finally, all ship's doctors must realize the 
heroism of releasing personnel from a burning or wrecked plane is not 
their privilege, That is the privilege and responsibility of men properly 
clothed and trained to do the job. It is the duty of a doctor to so protect 
his hands and arms as to be useful in performing the technical procedures 
that are expected of a graduate of medicine. 

In conclusion, it is desirable but not essential for a flight surgeon to 
be on the flight deck at flight quarters. Rigid restriction should be in effect 
only when the number of doctors on board is adequate to cover the need for 
a doctor elsewhere. 

Certainly, by properly presenting these concepts to their respective 
air officer, executive officer, and commanding Sfficer, each senior medical 
officer will enjoy the understanding and cooperation of these officers. 
(ComNavAirLant Special Edition, Medical News Letter, 26 September 1958) 

Jj: sj: ;^ 3J; >}: 5|c 

Letter of Commendation 

Lieutenant R. H. Tabor MC USN has been awarded a Letter of 
Commendation by the Secretary of the Navy for service as set forth in the 
following citation: 

"For outstanding performance of duty while serving as the Flight 
Surgeon and a Test Officer on the Full Pressure Suit Evaluation Project 
being conducted by Air Development Squadron Three, U. S. Naval Air 
Station, Oceana, Virginia, and the Full Pressure Suit Training Unit, 



33 Medical News Letter, Vol. 33, No. 4 



U. S. Naval Air Station, Norfolk, Virginia, from 5 to 8 September 1958. 
Entirely dependent upon the full pressure suit to protect him from the 
effects of extreme simulated altitudes during a continuous 72-hour period 
in a low pressure chamber, Lieutenant Tabor reached a maximum altitude 
of 139 j 000 feet and remained at an altitude higher than 80, 000 feet for 
38 hours of the test period, the. longest time man has ever been subjected 
to such extreme simulated or actual altitudes. By his outstanding pro- 
fessional knowledge, he was able to determine, observe, and report 
accurately and objectively the biological effects incident to this test, there- 
by providing valuable information relating to the future improvement of the 
full pressure suit. Lieutenant Tabor's initiative, leadership, and devotion 
to duty were in keeping with the highest traditions of the United States 
Naval Service. " 

Lieutenant Tabor is presently assigned to duty with Air Development 
Squadron Three, U.S. Naval Air Station, Oceana, Va. By the letter of com- 
mendation he has been authorized to wear the Commendation Ribbon with 
Metal Pendant. 

^c s;« i\t ;}: s}: ^; 

The 1959 Aero Medical Association Meeting 

The Aero Medical Association will hold its 30th annual meeting at the 
Statler Hotel, Los Angeles, Calif. , on 27, 28, and 29 April 1959. Approx- 
imately one hundred and twenty-five (125) professional papers will be pre- 
sented in three simultaneously conducted sessions. The scientific program 
has been arranged under the direction of Brigadier General Don Flickinger, 
USAF (MC), Chairman of the Scientific Program Committee. The Navy, 
Air Force, and Royal Canadian Air Force will present scientific exhibits, 
and the leading drug and equipment companies will exhibit their latest 
advances in aviation medicine. Reserve officers may receive retirement 
point credits for attending this meeting. 

The Wives' Wing of the Association ha.3 developed an extremely attrac- 
tive program for the ladies. Your wife will have a wonderful vacation in 
Los Angeles. 

It it- hoped that government air transportation for many active duty 
flight surgeons cau be made available. All flight surgeons are urged to 
attend this meeting. Here you will have an opportunity to see more flight 
surgeons than at any other time. Make your plans to be present and to 
participate in the scienfitic deliberations and the social events. Bring 
your wife to Join in the program of the Wives' Wing. This will be the best 
meeting of them all. 

Pfi *fi SJI *fi rfi Jj? 



Medical News Letter, Vol. 33, No. 4 39 



Aviation Toxicology 

"Teflon, " the trade name for a plastic resin, is ideal as a seal or 
washer for moving parts. It provides a practically friction free surface 
which is free of water absorption. It is also used as insulation for elec- 
trical wiring. Unhealed, it is completely non-toxic. At 400° F. , a gas 
is given off known as perfluorisobutylene. This gas is colorless, odor- 
less, and as toxic as phosgene. At 1000O F. , almost 20% of the hydro- 
lytic products of Teflon consists of this poisonous gas. Mechanics should 
be earned against using torches in the presence of this plastic. Further- 
more, they should be warned that waste products of Teflon should be buried 
rather than burned. (Extract from ComNavAirLant Medical News Letter of 
September 1958) 

Walking Blood Bank 

Most ships have some form of blood donor lists prepared. Many 
smaller units would be wise to do the same. The following is an excerpt 
from a report written by Doctor R.G. Merritt, one-time Medical Officer 
for the USS ALBANY. "A 'Blood Bank Log' was compiled with a page for 
each of the eight blood types (A positive, A negative, B positive, B nega- 
tive, AB positive, AB negative, O positive, and O negative). The name 
of each person being studied was entered on the page of his blood type 
along with his rate, service number, and division, in order to facilitate 
immediate contact when necessary. Studies were continued until a suf- 
ficient number of persons of , each were obtained. Kahn tests were re- 
peated at intervals to guard against syphilitic infection and results record- 
ed in the log. " (Extract from ComNavAirLant Medical News Letter of 
September 1958). 

CAA Now FAA 

Effective in early 1959, the Civil Aeronautics Administration became 
a part of the newly organized Federal Aviation Agency. Mr. E. R. Quesada 
is Administrator of the FAA. Doctor J. E. Smith, formerly Chief, Medical 
Division, CAA, is Acting Civil Air Surgeon. Your attention is invited to the 
recently issued BuMed Instruction 6120. HB which pertains to the issuance 
of FAA Second Class Airman's Medical Certificates to qualified Navy, Marine 
Corps, and Coast Guard personnel. 

* * * £ * * 



40 



Medical News Letter, Vol. 33, No. 4 



Flight Time 

The following message has been received in BuAer and is quoted below: 
"Pass to all Navy and Marine Air Activities 
your cognizance. Refer OpNav Instruction 
3710. 15B, Para. 5 B, C, & D. All minimums 
are waived for remainder of fiscal year. " 
Paragraphs 5 C and D refer to the annual minimum flight hour require- 
ments for flight surgeons. 

****** 

New JCAP Of ficers 

The Joint Committee on Aviation Pathology has announced the election 
of CAPT Carl E. Wilbur MC USN as Chairman and CAPT Murray W". Ballenger 
MC USN as Secretary. The JCAP encourages basic and applied collaborative 
research in aviation medicine and pathology. 

* * * * * * 



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